Head Injury

Question 1

Discuss the assessment and management of a minor head injury.

Answer 1

Ax: alert/normal conscious state, no LOC, vomiting <2 episodes, mild scalp bruise/laceration, otherwise normal
Mx: discharge with head injury advice

Question 2

Discuss the assessment and management of a moderate head injury.

Answer 2

Ax: brief LOC, mild drowsiness, responds to voice, 2+ vomiting, persistent headache, one single/brief convulsion, scalp haematoma, otherwise normal
Mx: Close obs in ED for 4 hours, full neuro obs Q30 min (GCS, pupils, limb strength and vitals), immediate head CT when indicated (see other card), if normal by 4 hours post-injury –> home with head injury advice

Question 3

For a patient with deterioration in the context of moderate head injury, what are the criteria for a CT brain?

Answer 3

Deteriorating, ongoing vomiting, any concerns, fails to improve by 2 hours post-injury

Question 4

List the assessment findings for a severe paediatric head injury.

Answer 4

Prolonged LOC, decreased GCS (poorly responsive), focal neurology, signs of increased ICP, signs of base of skull fracture, penetrating head injury, prolonged seizure (> 2 minutes)

Question 5

Discuss how you would manage a patient with a severe head injury.

Answer 5

Prevent secondary injury = control airway, BP and sats. C-spine protection. Early neurosurgical/ICU consults. Reduce ICP = 30 degrees head up, pCO2 35-40, consider mannitol. Control seizures and urgent CT brain.

Question 6

What is the dose of mannitol or hypertonic saline in paeds head injury?

Answer 6

0.25-0.5 g/kg over 20-30 minutes IV

Hypertonic saline: sodium chloride 3%, 3 ml/kg over 10-20 minutes IV

Question 7

How do you control seizures in children?

Answer 7

Midazolam 0.15 mg/kg IV and phenytoin load 15-20 mg/kg

Question 8

What are the exclusions with the PECARN criteria for C-spine injuries?

Answer 8

GCS <14, trivial mechanism, penetrating trauma, brain tumour/VP shunt/neuro disorder, bleeding conditions

Question 9

How do you divide the patients with the PECARN rule?

Answer 9

Into <2 and 2-18 years

Question 10

Discuss the PECARN rule for children <2 years old.

Answer 10

Normal mental state, behaving normally as per parent, LOC <5 seconds, no severe mechanism (MVA, fall >1 m).
No palpable skull fracture and no scalp haematoma (apart from frontal)

Question 11

Discuss the PECARN rule for children 2-18 years old.

Answer 11

Normal mental state (= not drowsy, confused or agitated), no LOC, no vomiting, no severe headache, no severe mechanism, no signs of base of skull fracture

Question 12

What would you advise a parent who is about to go home with their head injured child.

Answer 12

1) Parental supervision for the next 24 hours, 2) Return to hospital if: unconscious/ALOC, confused, seizure, persistent headache, repeated vomiting, bleeding/watery discharge from ears/nose.

No contact sports for at least 1 week. Give head injury leaflet.

Question 13

Describe the AVPU score.

Answer 13

A: alert
V: responds to voice
P: responds to pain
 - purposefully 
 - non-purposefully 
U: unresponsive

Question 14

What are indications for neuroimaging in a child.

Answer 14

1) Any sign of base of skull fracture on secondary survey,
2) Focal neurological deficit
3) Suspicion of open/depressed skull fracture
4) Any GCS <8
5) GCS persistently <13
6) Suspected NAI
7) Any seizure > 2 minutes post-impact

Question 15

What patients require c-spine immobilisation?

Answer 15

History of trauma +
1) Unconscious, 2) Complaining of neck pain + midline tenderness +/- limitation of movement, 3) Using hands to support neck, 4) Neuro deficit, 5) Significant facial/torso/head injuries, 6) Traumatic torticollis, 7) Substance affected, 8) Conditions that predispose to injury

Question 16

What are the conditions that may predispose to a significant c-spine injury?

Answer 16

Rheumatological, congenital, metabolic, genetic conditions or prior c-spine surgery

Question 17

What can be said about ‘distracting injury’?

Answer 17

Any injury below the upper torso should not be regarded as a distracting injury for the purpose of c-spine assessment and removal of a c-spine collar as per RCH guidelines.

Question 18

Discuss what patients who are unable to be adequately assessed, require a c-spine collar.

Answer 18

Those who have a history of:

1) Ped/cyclist vs car >30 km/hr, 2) Passenger MVA >60 km/hr,
3) Fall > 3m,
4) Kicked by, fall from horse,
5) Backed over by car,
6) Thrown from vehicle,
7) Severe electric shock

Question 19

What is TED and how does it relate to C-spine injury?

Answer 19

TED: thoracic elevation device. Should be used for children <8 years to keep their cspine in neutral position

Question 20

What is the neck injury more common than a fracture in children <8 years?

Answer 20

Occipital-cervical dislocation

Question 21

What is the most prominent vertebra on palpation?

Answer 21

C7

Question 22

What do you xray for a <5 year old with suspected neck injury?

Answer 22

AP and lateral xray only

Question 23

What do you xray for a 6+ year old with suspected neck injury?

Answer 23

AP, lateral and odontoid xrays

Question 24

What needs to be included in a lateral neck xray?

Answer 24

Occiput to T1 (may require shoulder traction)